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Guidance or Compliance: What Makes an Ethical Behavior Analyst?

Article · October 2018

DOI: 10.1007/s40617-018-00287-5

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DISCUSSION AND REVIEW PAPER

Guidance or Compliance: What Makes an Ethical Behavior Analyst?

Nancy E. Rosenberg1,2 & Ilene S. Schwartz1,2

# Association for Behavior Analysis International 2018

Abstract In 2016, the Behavior Analyst Certification Board (BACB) made effective a new, revised ethical code for behavior analysts, the Professional and Ethical Compliance Code for Behavior Analysts, replacing the code that had been in effect since 2001. In this revised code, the certification board has shifted the language of the code from that of a set of guidelines to that of a set of enforceable rules. This important shift has not been well discussed in the field. This article explores the potential implications and possible consequences of such a shift and describes other ways that ethical behavior has been approached historically. The authors then propose an ethical decision-making process that might provide a better area of focus for the field of behavior analysis in seeking to develop the highest levels of ethical behavior in its professionals and provide a case example using that process to resolve an ethical dilemma.

Keywords Ethics . Behavior analysis . BACB compliance code . Ethical dilemmas . Professionalism

The field of behavior analysis has experienced tremendous growth and change over the past 40 years. In 1977, there were approximately 1,100 members of the Association for Behavior Analysis International (ABAI; Deochand & Fuqua, 2016); in 2017, there were over 7,500 members (Dougher, 2017). In 1977, approximately 1,200 behavior analysts attended ABAI’s annual conference (Kangas & Vaidya, 2007); in 2017, over 5,000 attended the conference (Dougher, 2017). In 1977, there was no formal credentialing or licensing of behavior analysts anywhere in the world (behavior analysts, if licensed at all, had to be licensed under the umbrella of other disciplines, such as psychology); in 2017, there were over 25,000 master’s and doctoral-level behavior analysts credentialed by the inter- national Behavior Analyst Certification Board (BACB; www. bacb.com), and 26 states in the United States have mechanisms to license these professionals (Association of Professional Behavior Analysts, 2017).

* Nancy E. Rosenberg [email protected]

1 Special Education, College of Education, University of Washington, Box 357925, Seattle, WA 98195, USA

2 Haring Center, University of Washington, Box 357925, Seattle, WA 98195, USA

The growth in the field has been fueled primarily by the use of applied behavior analysis (ABA) with individuals with autism and by the concomitant health insurance funding for these services. Stemming largely from the seminal Lovaas (1987) study, which demonstrated a remarkable response to intervention by 9 of the 17 children with autism receiving intensive ABA therapy, and supported by an ever-increasing body of research (e.g., Wong et al., 2015), ABA has become the primary evidence-based treatment for autism. By 2017, 43 states and the national Medicaid program had mandated insur- ance coverage for ABA for children with autism spectrum disorder (Autism Speaks, 2017).

This explosive growth brings a corresponding increase in concerns about the ethical behavior of behavior-analytic prac- titioners, particularly because the growth in the field has pri- marily been in the area of developmental disabilities, involv- ing some of society’s most vulnerable members. There is a long history of mistreatment and abuse of this population, often in the name of therapeutic intervention (Dittrich, 2016; Donvan & Zucker, 2017). Some of this history of misconduct has unfortunately included the work of those claiming to be using behavioral treatments (e.g., Goldiamond, 1974; Kix, 2008; McAllister, 1972). Behavior analysts still combat this association, and it will likely take decades of exemplary eth- ical behavior for the field to break the link. Thus, an ongoing conversation about how to promote top-quality standards of professional and ethical behavior is paramount.

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As the primary accreditation body for behavior analysts, the BACB has taken the lead in articulating what the ethical behavior of a behavior analyst should look like. In 2001, at the advent of certification, the BACB published a code of conduct called Guidelines for Responsible Conduct for Behavior Analysts (BACB, 2001). Fifteen years later, the BACB made effective a revised code, the Professional and Ethical Compliance Code for Behavior Analysts (hereafter referred to as the BACB Code; BACB, 2014a). Any behavior analyst who wishes to obtain certification at any level through the BACB must agree to abide by this code. Hence, because of the number of behavior analysts choosing (or required by licensure or insurance requirements) to become certified, the BACB Code has become the de facto document articulating behavior-analytical ethics and professionalism.

Although the scholarly work offering in-depth discussion and analysis of ethics in behavior analysis is sparse, there have been a number of articles in the past decade that have delved into specific aspects of the BACB ethical code. LeBlanc, Heinicke, and Baker (2012), for example, explored ethical methods for behavior analysts to build boundaries of compe- tence. Several authors (e.g., Brodhead, 2015; Schreck & Miller, 2010) have provided discussion of how behavior ana- lysts can make ethical and professional decisions regarding the use of alternative and nonbehavioral treatments. O’Leary, Miller, Olive, and Kelly (2017) provide an in- depth discussion of social media and the ethical practice of behavior analysts. Several authors (Sellers, Alai-Rosales, & MacDonald, 2016; Turner, Fischer, & Luiselli, 2016) have addressed issues related to ethical supervision.

One aspect of the revised 2016 BACB Code that has not been discussed in the literature is the transition from the char- acterization of the code as a set of guidelines for ethical prac- tice to the characterization of the code as a set of enforceable rules. The original code that guided the ethical behavior of Board Certified Behavior Analysts (BCBAs) from 2001 to 2016 was called the Guidelines for Responsible Conduct for Behavior Analysts. The introduction to that code stated, “The Guidelines are provided for general reference to practitioners, employers, and consumers, of applied behavior analysis ser- vices … these Guidelines … are not separately enforced by the BACB” (BACB, 2001, p. 1; emphasis added). The word “guideline” was used throughout the code to refer to the indi- vidual elements guiding ethical practice.

The new code effective in 2016, on the other hand, is pre- sented as a list of enforceable rules rather than guidelines for behavior. The term “guideline” has been removed from the title, the Professional and Ethical Compliance Code for Behavior Analysts, and has also been completely removed from the document itself. In addition, the BACB has stated that “the Code will be enforceable in its own right and in its entirety” (BACB, 2014b). Thus, the BACB has moved from a stance of providing guidance on how to act ethically to a

stance of seeking compliance with a set of rules for practicing ethically.

This is a significant change. It assumes that there is a set of rules that can define ethical behavior for a behavior analyst in all circumstances and that ethical behavior can best be achieved by policing adherence to that set of rules. The pur- pose of this article is to explore this issue. We identify some of the perhaps unintended consequences of such a directive view of ethics and describe other ways that ethical behavior can be approached. Finally, we suggest an ethical decision-making process that we believe might provide a better area of focus for the field in seeking to develop the highest levels of ethical behavior in its professionals. As we are behavior analysts practicing in the field of developmental disabilities, we focus our examples from our scope of practice but hope that our exploration of the topic encourages behavior analysts from all areas to consider the questions we raise.

Rule-Based Ethics

The idea that there is an absolute set of rules that can govern moral behavior is called deontology, or rule-based ethics (Fisher, 2016, p. 38; Kant, 1785/1959). In deontology, the morality of an action is dictated by its adherence to a rule. Deontology is based on an assumption that it is possible to establish a set of rules or principles that can articulate ethical behavior in all circumstances and across all contexts and that if everyone then adheres to those rules, ethical behavior will be assured. Such an approach has great appeal in that it avoids any suggestion of a subjective approach to ethics: It keeps people from making selfish exceptions for themselves in what constitutes ethical behavior (Shafer-Landau, 2013, p. 442).

However, a rule-based approach can sometimes present problems. We have encountered some of the inherent issues related to this approach in our workwith the BACBCode. The issues that can arise often fall into one of three categories: (a) situations where the context of the ethical dilemma seems to argue against the rules, (b) situations where two or more rules can conflict, or (c) situations where cultural considerations seem to suggest a different course. We consider each of these potential conflicts in turn.

Context Sometimes Matters

Ethicists have argued for centuries about whether there are moral absolutes that apply in every situation. Even with a seemingly straightforward moral admonition such as “Thou shalt not kill,” it is relatively easy to come up with scenarios where adhering to the rule might not be considered the ethical course. Many people who believe generally that killing is a bad thing would agree that to kill a terrorist as he prepares to detonate a bomb designed to kill thousands of innocent people

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would be the right ethical decision. Similarly, the moral state- ment that “one should tell the truth” seems to be a straightfor- ward ethical rule, but again, we can quickly imagine situations where telling the truth may not be the best, or most ethical, course of action. The classic example is that of a German citizen hiding a Jew during the Nazi regime of World War II. Nazis come to the house and demand to know whether any Jews are hidden inside. Most people today would agree that in this situation, lying is the most appropriate ethical behavior. As a guideline or rule of thumb for ethical behavior, “one should tell the truth” works well; however, as an inflexible rule applicable in every circumstance, it runs into problems.

There are a number of scenarios where rules from the BACB Code can be similarly affected by context. Consider code 1.05(d): “In their work-related activities, behavior ana- lysts do not engage in discrimination against individuals or groups based on … socioeconomic status.” As a guideline for behavior, the statement that behavior analysts will not dis- criminate against those without economic means is principled and unarguable. But what it implies, as an enforceable rule, is that a behavior analyst running an agency must take every client coming to his or her door, regardless of the client’s ability to pay either privately or throughmedical insurance; otherwise, a behavior analyst is discriminating based on socioeconomic status. Although most agency representatives would agree that they have some responsibility to provide services regardless of a client’s ability to pay, most would follow this with the state- ment that they would quickly go bankrupt if they took every client who did not have the ability to pay. Agencies grapple every day with the difficult moral dilemmas of how to serve low-income clients and still stay in business (arguably another moral imperative). As a guideline for ethical behavior, this code is strong; as an enforceable rule, true in every situation, the code is problematic and impossible to comply with.

Code 1.06(a) provides another example. The code states, “Due to the potentially harmful effects of multiple relation- ships, behavior analysts avoid multiple relationships.” The potential ethical and professional problems associated with multiple relationships is an important ethical concept for be- havior analysts to understand and, in general, to avoid. But it is also possible to find situations that might argue for an alter- native approach. Consider a behavior analyst named Clarice, living in a university town. Clarice’s 3-year-old daughter is diagnosed with a developmental delay and is exhibiting severe self-injurious behavior. At the local university, there is a be- havior analyst who has significant expertise in self-injurious behavior. Unfortunately, this professor is also Clarice’s former professor and has since become Clarice’s friend and col- league. Clearly, Clarice’s child receiving services from this behavior analyst constitutes a multiple relationship. But this is a complicated situation. Is it right that Clarice should have to forgo the expertise of a clear expert in her child’s presenting problem because this person happens to be a friend and

colleague? Is it possible to carefully set up the situation to avoid potential issues caused by the multiple relationship while still allowing Clarice to get the best for her daughter? The point here is not to say what the right course is in this instance but rather to illustrate that these dilemmas can some- times be difficult and complex situations, not easily addressed by a black-and-white rule.

Two or more Moral Rules can Conflict

In deontological ethics, you can also find situations where two moral rules conflict. This happens frequently in daily life. “Be honest” and “be kind” are two common moral rules. But when presented with a friend’s stunningly bad haircut and asked, “How do you like it?” it may be impossible to be both honest and kind. Similarly, there are situations where two or more rules in the BACB Code come into conflict, making it literally impossible for a behavior analyst to abide by all codes. Take, for example, a situation where a behavior analyst is dealing with a significant personal issue, such as a divorce, which is impacting her work. Code 1.05(f) states that “behavior ana- lysts refrain from providing services when their personal cir- cumstances may compromise delivering services to the best of their abilities.” On the other hand, this behavior analyst has also clearly made commitments to multiple clients to provide service. Code 1.04(c) states, “Behavior analysts follow through on obligations, and contractual and professional com- mitments with high quality work.” Both codes are right, but the behavior analyst cannot simultaneously do both.

In another example, consider the situation where a behavior analyst cannot come to an agreement with an insurance com- pany on what constitutes an appropriate level of service for a client. Code 2.04(d) says,

Behavior analysts put the client’s care above all others and, should the third party make requirements for ser- vices that are contraindicated by the behavior analyst’s recommendations, behavior analysts are obligated to re- solve such conflicts in the best interest of the client. If said conflict cannot be resolved, the behavior analyst’s services may be discontinued following appropriate transition.

This behavior analyst has advocated for the client without success and thus the code suggests she may need to end ser- vices. However, 1.04(c) again states that behavior analysts need to follow through on obligations and professional com- mitments. The family may very much want the behavior ana- lyst to continue, even at a level of service below that which the behavior analyst feels is necessary. Both codes are right, but the behavior analyst cannot simultaneously do both.

True ethical dilemmas are often not those where there is a clear right and a clear wrong. True ethical dilemmas often

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arise when ethical principles seem to require a person to do two (or more) actions but the person cannot do both (or all) of the actions. Thus, in a world of rules enforceable in their entirety, the person seems condemned to ethical and moral failure no matter what she or he does.

Culture Always Matters

In today’s multicultural world, cultural considerations, wheth- er spoken or unspoken, unequivocally matter in ethical deci- sion making. The need to understand and balance a respect for the different worldviews of clients is paramount in entering into a productive professional relationship with them; clients and behavior analysts may have different values, beliefs, and views of behavior analysis but need to come to a common understanding and place of respect to move the relationship forward. Several authors have highlighted instances where cultural values and beliefs of clients may affect a behavior analyst’s practice (Fong, Catagnus, Brodhead, Quigley, & Field, 2016; Fong & Tanaka, 2013). It is impossible to pro- pose a set of rules that fits every cultural situation. Cultural beliefs and practices vary widely and are influenced by a va- riety of personal, family, and societal issues. Probably one of the most debated codes in the 2016 revised edition of the BACB Code has been code 1.06(d): “Behavior analysts do not accept any gifts from or give any gifts to clients because this constitutes a multiple relationship.” Some behavior ana- lysts have interpreted this as applying to even the smallest gestures by a family, prohibiting behavior analysts from accepting a cup of tea or a token gift (Bailey & Burch, 2016). However, in many cultures, accepting a beverage or food when entering a house is considered a common courtesy and refusing is considered rudeness. In many school environ- ments, accepting a token gift at holiday time is part of school culture and being the one member of a school team to refuse the token gift from parents at the end of the year may be seen as a sign of arrogance or as an implication that other members of the school team are acting unethically. In both situations, refusing the gesture risks damaging relationships. Again, we are not proposing what the right or wrong thing to do is in these situations; rather, we are arguing that these situations are complex, that consequences of either action need to be weighed, and that a consideration deeper than a black-and- white rule is needed.

Reliance on scientific knowledge is a bedrock principle of behavior analysis and is included in several of the BACB Code rules, such as code 1.01, “Behavior analysts rely on professionally derived knowledge based on science,” and code 2.09(a), “Clients have a right to effective treatment (i.e., based on the research literature …). ” However, cultur- ally diverse clients may not have the same faith in scientific evidence that a behavior analyst has. Consider a situation where a behavior analyst is working to build a relationship

with a family who has recently moved to the United States from another country. This family is highly skeptical of be- havior analysis, and the behavior analyst has been working very hard to establish the trust necessary to do her work and help her client. The family wants to try a nonscientifically supported treatment popular in their culture and that has enjoyed favorable reports in the popular press. The behavior analyst believes that this treatment would be harmless and take very little time and that agreeing could greatly improve the relationship with the family. The behavior analyst also fears that without this collegial approach, the family will de- cide to abandon ABA altogether. This behavior analyst could reasonably decide, after a careful weighing of consequences, that in this situation, deciding to include this nonscientific treatment in a robust package of behavioral interventions is the most ethical course. Once again, it is not the final decision we are promoting, but rather the fact that these are complex situations requiring careful analysis rather than black-and- white rules.

It is important to remember that the culture of the behavior analyst also impacts ethical behavior. The belief that a rule- based system, where everybody following the rules produces the greatest good, is a Western-centric belief (Zheng, Gray, Zhu, & Jiang, 2014). Zheng et al. (2014) compare this Western stance with traditional Chinese ethical beliefs, which emphasize the maintenance and propriety of relations as the most important consideration in determining the greatest good. In traditional Chinese thinking, human relationships are considered more important than any other aspect of human life and a rule should not be followed if it promotes disharmo- ny (Zheng et al.). Thus, considering an ethical dilemma, a Chinese behavior analyst is likely to form a very different analysis than a Western-raised behavior analyst would. As behavior analysis spreads throughout the world, it becomes increasingly important that the profession has an approach to ethics that can respect cultural differences.

Other Approaches to Ethical Decision Making

Rule-based decision making, or deontology, is not the only way to approach ethical decisions. Ethicists and philosophers have proposed a number of different methods for ethical de- cision makers over the centuries, including virtue ethics and ends-based ethics.1

Virtue ethics, first expounded by Aristotle (trans. 1999), is very different from rule-based ethics. Virtue ethics involves a commitment to being a good and virtuous person. Ethical decisions are based on what a person decides is most virtuous in a given situation. Virtue ethics specifically says that what a

1 An excellent online resource for a nonspecialist’s introduction to ethics is The Stanford Encyclopedia of Philosophy (https://plato.stanford.edu/).

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person should do in a particular situation cannot be deter- mined beforehand or dictated by a set of rules (Shafer- Landau, 2013, pp. 609–686). Virtue ethics proposes that al- though ethical situations may have common aspects, each ethical situation is unique and complex and the contextual factors of each must be considered on their own.

Another approach to ethical decision making is ends-based ethics, also known as consequentialism or utilitarianism (Fisher, 2016, p. 38; Mill, 1861/1957). In ends-based ethics, a person focuses on the potential consequences of different actions in an ethical conundrum and then attempts to pick the action that will result in the best outcomes for the greatest number of people affected by the action. Again, this is very different from rule-based ethics. In rule-based ethics, an individual focuses on adherence to a general rule regardless of the consequences of complying with that rule in a given situation. Consequentialism focuses instead on the outcomes of different decisions in a particular situation.

All of these approaches to ethical decision making, not just deontology, have problems associated with them, which is probably why, after centuries of debate, none has been settled upon as the ideal approach to ethical decision making. An in-depth discussion of the pros and cons of each of the approaches is beyond the scope of this article. However, it is important for behavior analysts to know that there are other ways to think about ethical behavior. In fact, Kidder (2009) has argued that systematically considering an ethical dilemma through the lenses of different ethical approaches is fundamental to ethical decision making.

Ethical Decision Making as a Process

We have called into question whether there is a set of rules that can define ethical behavior for behavior analysts in all circum- stances. A stance that one cannot define such a set does not necessarily imply an ethical free-for-all where any decision goes. We in fact believe that a set of guidelines for ethical and professional behavior—an ethical code for our profession developed by experienced, knowledgeable, thoughtful, and diverse members of our profession—is critical in guiding eth- ical professional behavior. Behavior analysts at any level must start by studying this code, developing a deep understanding through discussion, practice, and role-playing of both the practical purpose of each guideline and the important reasons behind each one. We believe, however, that ethical decision making should then be a process of systematically evaluating an ethical dilemma, considering not only the profession’s eth- ical guidelines but also other factors that might influence an ethical decision. For someone to deviate from the published guidelines, this process would expect that person to

demonstrate that he or she has diligently and systematically thought about the issue, weighed carefully the pros and cons of each course of action, documented his or her deliberations, and then made a careful decision.

Ethical Fitness

The idea that fluent ethical behavior requires constant practice has been around since Aristotle, who maintained that to be truly virtuous, one must practice ethical behavior until it be- comes habit (Aristotle, trans. 1999). In a more modern version of this idea, Kidder (2009) talks about the need to have “eth- ical fitness.” Ethical fitness shares many similarities with physical fitness. Just as the achievement of physical fitness requires regular, ongoing exercise, true ethical fitness also requires regular, ongoing ethical practice. Every day, behavior analysts are confronted with situations in which they need to make decisions about how they will conduct themselves. Many of these occurrences are mundane situations requiring little thought, but others are complicated and delicate and have a variety of possible resolutions. To be able to consis- tently act ethically in both the mundane and the more complicated situations, behavior analysts must be fluent with the skills and knowledge required. And just as a structured fitness routine, practiced daily, can help one achieve physical fitness, we propose that a structured ethical decision-making process, practiced frequently, is an ideal way to achieve ethical fitness.

A Possible Ethical Decision-Making Process

Here we propose one version of an ethical decision-making process—one we have developed as we have struggled with students, colleagues, and other professionals to resolve ethical dilemmas. The process has gone through a number of itera- tions, and we suspect it will go through more as we invite a discussion in the behavior-analytic community about what such a process might look like. The process can be seen in Fig. 1. We address each step only briefly here, as the purpose of this article is not so much to propose a particular decision-making process as it is to propose the idea that focusing on an ethical decision-making process, rather than working toward an ever more detailed set of rules, is the best direction for behavior analysts in develop- ing an ethical profession.

Step 1: Why does this trigger your ethical radar?

& Identify the ethical dilemma. & If applicable, identify the client(s). & Identify the relevant codes in the BACB Code. & Identify personal values or biases that may influence your

decision making on this issue.

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Fig. 1 Ethical decision-making process

Step 3: Evaluate solu�ons. Consider what issues, conflicts, or tensions might poten�ally influence each solu�on. Also consider the following:

Client safety Client dignity and self-determina�on Client outcomes Impact on your rela�onships with other par�es Family preferences

YES

Step 4: Have you found an acceptable solu�on?

Step 2: Brainstorm solu�ons. What solu�ons does the BACB Code suggest? What are other possible solu�ons?

Step 1: Why does this trigger your ethical radar? Iden�fy the ethical dilemma. If applicable, Iden�fy the client(s). Iden�fy the relevant codes in the BACB Code. Iden�fy personal values or biases that may influence your decision making on this issue.

NO

Step 6: Reflect upon the results/effects of your decision. Was it a successful resolu�on? Do you need to take any further steps in this par�cular situa�on? Have you learned anything that will affect future ethical decisions?

Step 5: Implement the solu�on with fidelity and carefully document all ac�ons taken.

Every good behavior analyst knows that before one at- tempts to change a behavior, one first needs to develop a clear operational definition of the behavior. The same is true in ethical decision making; before engaging in an analysis of an ethical dilemma, one must clearly articu- late the issue and identify the parties most affected by this issue.

As stated earlier, we believe that ethical decision making should start with adherence to a set of guidelines set forth by the profession. Currently, this is the BACB Code. Thus, the behavior analyst next must identify the specific codes in the BACB Code that apply to the stated issue. This requires that behavior analysts have a working knowledge of the BACB Code and are familiar enough with its contents to know which codes are relevant in a given situation.

Behavior analysts must also then think about the lenses through which they are viewing the potential ethical conflict. The personal lenses that influence our view of behavior and contexts may be influenced by culture, values, and beliefs. Although our study of ABA often ignores these influences,

it is impossible to examine ethics without acknowledging how these personal beliefs and values influence the interpretation of an ethical code and the decisions that we make around ethical and moral behavior (Tanaka-Matsumi, Seiden, & Lam, 1996). Abramson (1996) terms this awareness “ethical self-knowledge.”

Step 2: Brainstorm solutions.

& What solutions does the BACB Code suggest? & What are other possible solutions?

The next step in making an ethical and professional deci- sion is to brainstorm possible solutions. Behavior analysts can do this on their own, but talking through possibilities with a respected colleague or a group of colleagues will often result in a better set of options. Possible solutions should be influ- enced by the BACB Code, a behavior analyst’s professional experience, and other factors a behavior analyst considers rel- evant to a given ethical decision.

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Step 3: Evaluate solutions. Consider what issues, conflicts, or tensions might potentially influence each solution. Also consider the following factors when evaluating solutions:

& Client safety & Client dignity and self-determination & Client outcomes & Impact on your relationships with other parties & Family preferences

Once a behavior analyst has developed a list of po- tential solutions, it is time to evaluate the solutions and the effects each would have on involved parties. For each solution, it is important to consider both who will be affected by the decision and how. In our own work with individuals with developmental disabilities and their families, we have identified some specific factors that we believe should be part of this evaluation. These factors are derived from a set of universal moral values pro- posed by Kidder (2005): honesty, respect, responsibility, fairness, and compassion. In working with the decision- making process, we found these universal values to be too general to be particularly helpful; in consequence, we have developed a set of factors, derived from these prin- ciples but specific to our work with individuals with developmental disabilities, that we believe any ethical decision should take into account.

Step 4: Have you found an acceptable solution? Often, after working systematically through the possible ramifi- cations of different solutions, one solution will reveal it- self as clearly the best option. In this case, a behavior analyst can move ahead to Step 5, documenting the deci- sion and implementing it. Occasionally, however, a behav- ior analyst will carefully evaluate the solutions and feel that none is right; no solution will meet the behavior ana- lyst’s standard for ethical and professional behavior. In this case, the behavior analyst must go back to Step 2 and brainstorm new solutions. This is a point where true “out of the box” thinking is often needed. If colleagues have not been enlisted previously, this is an important time to bring them in. A number of professional organizations, including ABAI, provide an ethics consultation line that practitioners can call to discuss ethical dilemmas. An eth- ical behavior analyst will continue the process until a so- lution is found that meets his or her standard of ethical and professional behavior.

Step 5: Implement the solution with fidelity and carefully document all actions taken. When a behavior analyst de- velops a behavior plan to reduce or increase a client behavior, the behavior analyst must ensure that the plan is being imple- mented with fidelity before attempting to assess the

effectiveness of that plan. Similarly, an ethical behavior ana- lyst must implement an ethical solution with fidelity before assessing the outcome.

Careful documentation of the ethical decision-making process is critical throughout. We believe that systematic and thoughtful analysis of ethical dilemmas is the linch- pin of ethical behavior and that it is on this analysis that ethical behavior should be judged. Thus, it is crit- ically important that a behavior analyst documents the steps taken both in arriving at a decision and in carrying out the decision.

Step 6: Reflect upon the results/effects of your decision.

& Was it a successful resolution? & Do you need to take any further steps in this particular

situation? & Have you learned anything that will affect future ethical

decisions?

Finally, it is important to remember that settling on a solution to an ethical dilemma does not mean one can never change one ’s mind or adjust one’s course. Collecting information about the effects of an ethical de- cision enables a behavior analyst to evaluate the solution and to then engage in data-based decision making regard- ing future behavior. This type of evaluation may be less straightforward than evaluating behavior change on a line graph, but it is equally critical. It requires considering the effect a decision had on current clients, on other affected parties, and on one’s own feelings of confidence and competence.

This self-reflection on one’s behavior helps a behavior an- alyst decide whether a current dilemma has been successfully resolved or needs to be revisited. It is also critical to ethical fitness, helping a behavior analyst learn from both mistakes and successes, building both skill and fluency in ethical performance.

Case Example

To help illustrate our process, we consider the following eth- ical dilemma:

John works as a BCBA providing early intervention services for children with autism in a low-income, rural area. He is the only BCBAwithin a 160-km radius of his office. Recently, the 2-year-old son of John’s neighbor, a single mother three houses down, was diagnosed with autism. The family’s pediatrician referred the family to John for ABA services. John is struggling with how to handle the situation.

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Step 1: Why Does This Trigger Your Ethical Radar?

John first tries to clarify the ethical dilemma. He believes that accepting a neighbor as a client would constitute a multiple relationship and thus should be avoided. But he also is concerned that if he doesn’t provide service to this child, the child will not receive ABA services. Thus, his ethical dilemma is whether or not he should accept this child as a client.

Next, John tries to identify the clients in this dilemma. Although this family and this child are not officially his clients (he has not accepted them yet), he believes that in his analysis of the situation, he should consider the family and the child as clients, with the child being the prima- ry person of concern.

In reviewing the BACB Code, John believes the most per- tinent code is 1.06(a): “Due to the potentially harmful effects of multiple relationships, behavior analysts avoid multiple re- lationships.” However, he also highlights a statement from the introduction to code 2.0, “Behavior analysts have a responsi- bility to operate in the best interest of clients,” as he believes it may also be relevant to this situation.

Finally, John considers his own values and biases that may affect his decision. John acknowledges that he chose to live in this low-income, rural area because he was committed to serv- ing underserved populations. He feels that sometimes rules and regulations are made by people who do not understand the conditions he is operating under and thus he can feel dis- dain for those rules. He recognizes this tendency and tries to guard against it. Thus, he wants to make sure he is carefully considering why these rules exist and the dangers if they are not followed.

Step 2: Brainstorm Solutions

John believes the BACB Code suggests he should avoid this multiple relationship and refer the family elsewhere. He believes another possible solution is to take the family as a client but to try to set up safeguards against the dangers of the multiple relationship.

Step 3: Evaluate Solutions

John first considers the solution of referring the family elsewhere. Given that he is the only BCBA for 160 km, he examines the options. One of the alternatives would be to try to find a distant BCBAwho is willing to travel to their small town to provide services. However, John is aware that this parent has very limited financial means, and so John is not certain this is feasible. Another possibility is to try to find a remote BCBA who is willing to provide services via telehealth, but John knows this family does not have good Internet service (very few people in the neighborhood do),

and so John doubts that this would be a good option. Overall, given the challenges this mother is facing as a single mother with a newly diagnosed child, John is skeptical that she could sustain the challenges of remote services. He sus- pects that if he does not provide services, the reality would be that the child would not receive services at all. In addition, John wonders whether, even if the challenges of remote su- pervision could be addressed, the quality of the services pro- vided remotely could compare to the services he could pro- vide for this child when he could be providing close and fre- quent supervision.

John contemplates his second option: accepting the child as a client, but attempting to set up procedures that could help mitigate the potential problems of the multiple relationship. John believes he could discuss the situation and the dangers of the multiple relationship with the mother. He could specify that during the time the child is receiving services, John would need to avoid social encounters with this family as much as possible, and if occasions did unexpectedly occur, they would be kept as brief as possible and he and the mother would not discuss the child or his treatment at all. If unexpected neigh- borhood issues were to arise that required attention, the moth- er would interact with John’s wife about these issues rather than John.

John believes he has thoroughly analyzed his options, but he wants a second opinion. Although his rural situation means he has no immediate associates, he has maintained close rela- tionships with several colleagues from graduate school. He calls up one of his most trusted colleagues, someone he has always considered truly ethical in her behavior, and goes over the dilemma with her. This colleague agrees with John’s analysis.

Step 4: Have You Found an Acceptable Solution?

Although John is uncomfortable stepping knowingly into a multiple relationship, he believes that in this situation, it is the right thing to do. He believes that if he does not accept this child as a client, the family will not receive ABA services at all, and he believes this would be a greater wrong than the multiple relationship. He feels he has a good plan to provide safeguards against the dangers of the multiple relationship and feels that he is truly acting in the best interest of the child in choosing this path. Thus, he decides, yes, he has found an acceptable solution.

Step 5: Implement the Solution With Fidelity and Carefully Document All Actions Taken

John first takes the time to write down his considerations. He knows he is acting against a rule in the BACBCode and he wants to document his careful weighing of the pros and cons of the different possibilities. He then writes up a clear list of

Behav Analysis Practice

the parameters he has developed for the relationship. He will use this in his conversation with the mother and will keep it with his documentation of his decision- making process. John then moves forward with his meeting with the mother.

Step 6: Reflect Upon the Results/Effects of Your Decision

Six months later, John reflects on his decision and its consequences. There is no question that the child has benefited hugely from the ABA therapy. He is making great progress: starting to talk, developing play skills, and learning self-care. John also feels that he has safely navigated the multiple relationship. He and the mother rarely see each other outside of the clinic, and they keep those interactions brief, effectively avoiding discussion about the child or his services. John does feel that the situation has affected his life in the neighborhood a bit—he now always checks to make sure the family is not outside if he goes out to take a walk, and he chose to not attend the neighborhood barbeque last month so that he would not run into the family. But he feels that these are small, personal inconveniences compared to the good he is doing in providing this child with life-changing therapy. Overall, he feels extremely positive about the choice he made and its impact on the affected parties.

Summary

Behavior analysts are currently practicing under a system that views ethical behavior as adherence to a set of rules. We believe that such an approach does not promote truly ethical behavior. On the contrary, we believe that a rule- governed approach can promote a mechanical, rigid ap- proach to ethical behavior that does not adequately reflect the complex, diverse world that behavior analysts practice in. Rather, we believe that our ability to practice ethical- ly—our ethical fitness—is enhanced by an expectation that one constantly must wrestle in a thoughtful, system- atic way with ethical issues and then resolve issues in such a way that one could stand in front of a court of peers and defend one’s resolution and the reasons for it. To do this, behavior analysts must be taught a struc- tured, systematic way to approach ethical problems. We have presented one possible process for doing this, but the main purpose of this article is not to present our particular process but rather to stimulate a discussion in our field about how behavior analysts should approach ethics more generally. We believe all behavior analysts want to work in a profession whose members are committed to ethical be- havior. The question to be debated is how this can best be achieved.

Compliance with Ethical Standards

Conflict of Interest Nancy Rosenberg declares she has no conflict of interest. Ilene Schwartz declares she has no conflict of interest.

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